Medications at High Risk for Diversion and Abuse In Correctional Facilities

By Jeffrey E. Keller MD

Published: 04/24/2017

The practice of Correctional Medicine has many strange differences from medicine outside the walls. It took me a couple of years to get comfortable with the various aspects of providing medical care to incarcerated inmates. Of all of these differences, one that stands out in importance is the fact that many seemingly benign medications are abused in correctional settings.

Of course, the Drug Enforcement Agency (DEA) has established a list of drugs known to have potential for abuse and even addiction. The DEA even ranks these drugs according to the severity of this risk. Schedule I drugs carry the most risk, Schedule II, all the way down to Schedule V, which are thought to have the least risk.

However, the drugs that we are talking about here are not on the DEA’s list. These are medications that are not abused (or, at least, not thought to be abused) in mainstream medical settings. But these drugs are, in fact, abused and diverted in jails and prisons.

The reasons for this are somewhat complex, but in my mind, it boils down to this: These are drugs that have psychoactive effects that mimic, to some degree, the effects of the drugs on the DEA Schedules. If you are addicted, or even if you just like to get high once in a while, and you can’t obtain your preferred drugs of abuse because you are incarcerated, these are the drugs that can serve as an alternative in a pinch.

It is critically important for medical professionals in corrections to know which seemingly benign drugs have the potential to be abused and diverted. Even if a particular inmate doesn’t care about getting high himself, he can still profit by selling these drugs to others who are. Vulnerable inmates can be (and are) bullied into obtaining these drugs for distribution.

Like all correctional physicians, I myself have wrestled with the problems these drugs cause. Some have little therapeutic value and so are not such a big problem—I just don’t prescribe them. Others do have value but fortunately also have easy substitutes (therapeutic equivalents) that have less risk of abuse. But some drugs that are commonly abused in prisons are real problems because they have definite medicinal value and no ready substitutes. In these cases, practitioners have to weigh the expected benefits or this drug against the potential for abuse, diversion and harm. It is not always an easy decision!

But before we practitioners can make an informed decision about any such prescriptions, we have to know how the risks of many common medications are magnified in correctional settings.

This JailMedicine post categorizes the drugs that have abuse potential behind bars. I have divided the drugs with abuse potential into categories based on their primary psychoactive effect. Some are sedatives. Some are stimulants. Some are mainly sought because of they can produce euphoria, so I am going to call them the “Euphorics.” Of course, some drugs have multiple effects. Trazadone, for example, can be either a sedative or a euphoric, depending on how it is used.

Not all drugs have equivalent abuse potential and so, like the DEA, I have assigned each of these drugs according to its risk. The risk for a particular drug also can vary depending on the particular correctional facility you happen to be in. You might be having major problems with a drug in your facility that has not presented much of a hassle in my jails!

My chart also lists two other relevant facts: Does the drug have significant legitimate medical value? Does the drug have a ready substitute with less abuse potential?

I have NOT listed exactly how each drug is abused. Some methods are quite creative. I do not want to turn this into a “How-To” educational forum! If you find yourself scratching your head and wondering, “How in the world can that be abused?” you certainly may email me for the details that I do not want to list in a public forum.

Remember that no DEA scheduled drugs are listed here (with three special exceptions)—only those drugs that tend to be considered “benign” in outside medicine, but are commonly abused in correctional facilities.

The Sedatives. The sedatives are drugs obtained primarily for their sedative effects. These are drugs commonly sought—and prescribed—as sleeping aids. On the outside, controlled substances such as Ambien or benzodiazepines are more commonly used as sleeping aids. In the correctional setting, these drugs are sought after as substitute sleeping aids.
Trazadone. Abuse potential HIGH (+++). Trazadone is a poor antidepressant and can easily be replaced with others. It hould rarely be prescribed.
Quetiapine (Seroquel). Abuse potential HIGH (+++). Seroquel is an good anti-psychotic, but Zyprexa, Risperdal, Abilify and others all have less abuse potential. Seroquel used solely as a sleeping agent can often be recognized by small doses (50-100mg) prescribed only at night.
Skeletal Muscle Relaxers. Abuse potential (++). Despite the name, SMRs do not relax skeletal muscle. They are sedatives only. Their use should be uncommon, prescribed for acute muscular conditions only, and limited to 7 days or less.
Mirtazepine (Remeron). Abuse potential (++) Remeron is a sedating antidepressant. There are many antidepressants with less abuse potential.
Amitriptylline (Elavil). Abuse potential (++). Amitriptylline is the most sedating of the cyclic antidepressants. Many other cyclic antidepressants have much less abuse potential.
Doxepine. Abuse potential (+). Doxepine is sedating due to high anticholinergic properties. Many other cyclic antidepressants have much less abuse potential.
Clonidine. Abuse potential (+). Clonidine is commonly prescribed as a treatment for nightmares, but since it is sedating, it is sought as a sleeper. Clonidine is an essential drug for opioid withdrawal. It is not an appropriate HTN medication.

The Stimulants. The stimulants are drugs can mimic the effects of street stimulants like methamphetamine.
Albuterol. Abuse potential (++). Albuterol is an essential drug for the treatment of asthma and COPD. However, it also can cause a serious toxic syndrome. There are no ready substitutes. Clinicians must balance the risk of abuse versus the legitimate benefits. Besides the stimulant effect, albuterol is also inappropriately used as an “exercise enhancer.”
Pseudoephedrine. Abuse potential (++). Pseudoephedrine and the other decongestants are all poor cold medications. Many better medications for nasal complaints are available and so decongestants rarely need be prescribed.

Euphorics. These drugs are used to get a euphoric “high.”
Gabapentin (Neurontin). Abuse potential HIGH (+++). Gabapentin is commonly prescribed off label for neuropathic pain and other chronic pain syndromes. It unfortunately is often not recognized as a potential drug of abuse in the medical community at large. Duloxetine (Cymbalta) has been shown to be a superior drug for use in treating neuropathic pain. Gabapentin is the single biggest problem drug of abuse in many correctional systems.
Trazodone. Abuse potential HIGH (+++). Depending on how it is abused, trazodone can be primarily sedating or primarily euphoric. Trazadone is a poor antidepressant and can easily be replaced with many others.
Bupropion (Wellbutrin). Abuse potential HIGH (+++). Wellbutrin is an antidepressant with many acceptable substitutes such as venlafaxine (Effexor) and duloxetine (Cymbalta). Due to its high abuse potential, it should be rarely used.
Loperamide (Imodium). Abuse potential (++). Imodium is a commonly prescribed diarrheal treatment with opioid receptor activity. Imodium’s abuse potential should be considered when prescribing it, especially since most cases of mild diarrhea do not need any treatment. Here is a news article about loperamide abuse.
Venlafaxine (Effexor). Abuse potential (+). Effexor is an antidepressant with many substitutes such as Effexor and Cymbalta. Venlafaxine is not abused in all facilities
Topiramate (Topamax). Abuse potential (++). Topamax has legitimate use is as a seizure drug, though when sought illegitimately, it is usually requested as a psychiatric drug or headache medication.
Carbamazepine (Tegretol). Abuse potential (+). Carbamazepine has legitimate use as a seizure drug and a Bipolar drug but is a second or third tier drug for both indications. Better substitutes are available for both uses.

Psychedelics. The drugs abused for their psychedelic, sensorium altering effects are mainly drugs with anticholinergic effects. You know how goofy you feel after you take Benadryl? That’s what we are talking about.
First generation antihistamines. This includes all of the following medications: Benadryl (diphenhydramine), Vistaril (hydroxyzine), Chlorpheniramine (CTM), benztropine (Cogentin), and trihexyphenidyl (Artane). Abuse potential (++). Cogentin and Artane have legitimate use as treatments for dystonia caused by antipsychotics. The other first generation antihistamines are commonly used for allergic symptoms. However, second generation antihistamines such as loratidine (Claritin) and cetirizine (Zyrtec) have less abuse potential and often can be substituted.
Oxybutynin (Ditropan). Abuse potential (++). This is a drug commonly prescribed for overactive bladder symptoms, but is desired for its anticholinergic effects. Don’t underestimate this drug! One can get quite intoxicated on oxybutynin. The potential for drug seeking should be considered for atypical patients seeking this drug.
Diciclomine (Bentyl). Abuse potential (++). Bentyl is prescribed for Irritable Bowel Syndrome and abdominal cramps, but achieves its antispasmodic effects as an anticholinergic. The risk for abuse often outweighs the potential benefit of this drug. If Bentyl is used, it should be short term.

Non-mood altering agents. These medications are abused for reasons other than their psychiatric effects.
Psyllium powder. Abuse potential HIGH (+++). Packaged psyllium powder can be molded into a hardened shank. Since many benign fiber products available, psyllium should not be used in jails or prisons.
Stimulant laxatives. Abuse potential (++). Stimulant laxatives can be abused as a weight loss tool and can be quickly habituating. Non-stimulant laxatives are preferable in most cases.

Controlled substances: Three medications deserve special mention because it is sometimes not known that these drugs are DEA controlled substances.
Tramadol. Abuse potential HIGH (+++). Tramadol is DEA schedule IV. It is still commonly believed that Tramadol is not a narcotic (it is) and that it is not addictive (it is). In fact, in my experience, acute tramadol withdrawal tends to be more severe than withdrawal from many other narcotics.
Pregabalin (Lyrica). Abuse potential HIGH (+++). Lyrica is DEA schedule V. There is little difference (in my opinion) between Lyrica and gabapentin in both use for neuropathic pain or for abuse potential.
Carisoprodol (Soma). Abuse potential HIGH (+++). Soma is DEA schedule IV. All skeletal muscle relaxers have abuse potential, but Soma is the worst and should not normally be prescribed in correctional settings.

As always, the opinions presented here are mine and mine alone. Remember that I could be wrong! If you disagree, please comment and say why!

Have you had problems with any drugs in your facility that I have not listed here? Please comment!

Corrections.com author, Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of practice experience before moving full time into the practice of Correctional Medicine. He is the Chief Medical Officer of Centurion. He is also the author of the "Jail Medicine" blog

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